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Improve Revenue with HCC Coding
Hierarchical Condition Category (HCC) methodologies play a vital role in demonstrating illness complexity, assessing the health of populations, and reimbursement for healthcare services. HCC systems are designed to accurately predict risk by categorizing medical diagnoses into clinical conditions or groups of related conditions with varying degrees of severity or risk.
Providers bear more financial risk in a value-based healthcare system, underscoring the importance of demonstrating the complexity of the patient population being treated by documenting HCCs. Hierarchical Condition Categories are used to stratify risk and healthcare expenditures by commercial payers and Medicare for Medicare Advantage (MA) and the Medicare Shared Savings Program (MSSP).
The Medicare Advantage and Affordable Care Act (ACA) individual health insurance marketplace populations are both subject to risk adjustment and continue to expand, representing a sizable portion of insured beneficiaries in the U.S. More than half of eligible Medicare beneficiaries are currently enrolled in a Medicare Advantage plan.
Learning Objectives:
This course provides an overview of important concepts related to HCC coding. Successful risk adjustment and payment reimbursement require accurate reporting and proper provider documentation of a patient's illness severity. Providers and coders must follow ICD-10-CM guidelines when selecting diagnosis codes for an encounter, and determine whether to use all current and past conditions. Special care should be taken with selecting specific diagnosis codes for chronic conditions. It is important to know what types of unspecified codes do not carry a risk-adjusted factor (RAF). Practices often neglect to report status codes, and failure to do so has negative consequences in risk-adjusted diagnosis coding. It is imperative to improve documentation to replace unspecified codes with more specific diagnosis codes.
Risk adjustment relies on the consistent and accurate redocumentation of a patient’s conditions on an annual basis using ICD-10-CM codes. The risk score will not accurately characterize the patient’s risk to the plan if the chronic condition is not recaptured. Provider documentation is crucial for supporting a patient’s risk profile. Learn how to improve clinical documentation and avoid common HCC coding errors.
Walk through examples of identifying specific conditions, assigning HCC codes, and calculating a RAF score. Version 28 made significant changes to the risk adjustment model used in the Medicare Advantage reimbursement system. Risk scores and HCC coding have a financial impact on healthcare providers. Gain actionable tactics to foster and sustain HCC coding quality and ensure regulatory compliance to prevent fraud and abuse. Successfully identify missed opportunities that could positively impact the practice’s revenue cycle.
Full Schedule
Program times are Central unless otherwise noted.
| Session | Date | Time | Instructor | |
| 1 | September 25, 2025 | 11:00 am-2:00 pm | Kem Tolliver & Jan Hailey | |
| Fee: $239.00 | Register | |||
Live instructor-led online class includes digital companion materials.
CEUs:
| PMI | 3 |
Program Highlights:
- Understand the key concepts of HCC coding and distinguish among models
- Comprehend the relevance of ICD-10-CM guidelines to HCCs
- Know how to evaluate the use of unspecified codes and status codes
- Review examples of well-documented vs. poorly documented cases
- Apply HCC concepts to increase specificity in both primary care and specialty claims
- Understand RAF scores and M.E.A.T criteria for HCC validation
- Review hierarchical names/numbers introduced in V28 and current ICD-10 to HCC mappings
- Learn how Artificial Intelligence technology is utilized in risk adjustment programs
- Gain the facts on CMS's Risk Adjustment Data Validation (RADV) audits
- Using data analytics to monitor coding
- Know how HCCs relate to quality measures and the Medicare Wellness exam
- Review checklist for Data Accuracy and Integrity
- Leverage value-based care and identify best practices for HCC implementation
Who Should Attend
Medical coders, practice administrators, medical office managers, healthcare providers, and provider reimbursement related staff in practices participating in value-based payment programs, ACOs, and clinically integrated networks. This program will benefit anyone seeking to further their understanding and application of HCC coding concepts.
PMI's new Virtual Classroom experience allows for optimal interaction. Get your questions answered by the instructors in real time and build a network with your peers.
Registration includes live instructor led classroom instruction plus companion digital materials. A meeting link will be provided by email 2 or 3 days prior to the event.
About the Presenter(s)
Kem Tolliver and Jan Hailey
Kem Tolliver, CMOM, CPC, and FACMPE
Kem is the co-author of, "Revenue Cycle Management: Don't Get Lost in the Financial Maze" published by MGMA®. She also created and delivered the first-ever Revenue Cycle Management Certificate program on behalf of MGMA. Medical practices managed by Kem have received MGMA® "Better Performing Practice" distinctions in the areas of Accounts Receivable and Collections. As a national and regional SME, Kem develops and delivers educational content to industry leadership.
Mrs. Tolliver holds dual Bachelor of Science degrees in Healthcare Administration and Organizational Management; Summa Cum Laude and Magna Cum Laude respectively. Her certifications include: Certified Medical Practice Executive (CMPE), Certified Professional Coder (CPC) and Certified Medical Office Manager (CMOM). For over 20 years she has provided strategic and operational leadership to medical practices and hospitals. As the President of Medical Revenue Cycle Specialists, LLC (MRCS) her team leads Health Care Organizations in: Practice Start Up and Transformation, Revenue Cycle Improvements, Clinical Documentation Improvement, Educational Programing, Payer Contracting, HIT Software Development, EMR/PM software customization and Telehealth integration.
Kem has served on the Board of Directors of MD MGMA as the Chair of the Practice Management Committee and Chair of the Government Affairs Committee. She received MD MGMA's 2016 Outstanding Service Award and was the 2018 State of Maryland ACMPE Certification Rep.
Jan Hailey, MHL, CMC, CMCO, CMIS, CMOM, CMCA E/M
Jan Hailey has more than 30 years of experience in healthcare. She is proficient in administration, coding, and billing roles, and teaches medical office professionals around the country how to excel in their careers. Jan has also been instrumental in the development of PMI's Workforce Initiatives program.
Jan's affinity for teaching has helped countless healthcare providers and medical office professionals over the years. During her expansive career, she has served as Director of Quality for Saint Joseph Physician Network located in Mishawaka, IN, and Director of Care Management with Select Health Network, an entity of Saint Joseph Health System. As Care Management Director, Jan led the physician network and comprehensive interdisciplinary team across the health system working closely with providers, management, staff, community, and payers to develop strategies for process improvement, gap closures, and patient experience. She developed a documentation improvement program and a Hierarchical Condition Category (HCC) coding education program to predict future healthcare utilization by accurately reporting patient complexity.
Before joining Saint Joseph, Jan was the Director of Quality, Coding, and Compliance for one of the largest health systems in Northern Indiana. She has a Master of Health Leadership and four professional certifications in office management, coding, insurance processing, and compliance. She is a member of WPS Government Health Administrators (Medicare) Provider Outreach and Advisory Group.